GW1-2022-10829_Well Construction - GW1_20221209

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
it WATEBsIA ES'-0 �. K' ... .te a s
Shane Gossett FROM TO DESCRIPTIONI
WellContractorName 120 ft• 121 ft• I logpm
3528-A 135 % 136 ft- I I 20gpm
€tS111ERG 5ffiGl"or,'r3iulii Easc �eiilsOlF§I3Il!IER ra ifeotilc %
NC Well Contractor Certification Numbor FROM TO DIAMETERi I THICKNESS I MATERIAL
McCall Brothers, Inc. 1 ft. 1 95 % 6.25 i;ni 0.25 Galvanized steel
Company Name '57,6: h.1[tiCA'S1bC(4,�It'�.fiFllfll��l cofit`�EuiaL=EI�`acslgYiu i ��4 . ., :-�'"
FROM I TO DIAMETER THICKNESS MATERin
2.Well Construction Permit#: 13 841 0 ft. tt, in:
List all applicable well construction permits(Le.County.State,Variance,eta.) ft- ff. in.,
3.Well Use(check well use): v7 SCREEN r�zte `
r
Water Supply Well: FROM TO DIAMETER i SLOT SUM THICKNESS I MATERIAL
❑Agricultural ❑ umcipal/Public 1 ft. 120 ft. 4 in. 0.25 Pvc
❑Geothermal(Heating/Cooling Supply) 16esidential Water Supply(single) ft. ft. �•
❑Indpstrial/Commetcial ❑Residential Waters (shared) FR
OM
UU c
Supply OM TO MATERIAL EMPLACEMENTMETHODt4AM0II7VT
❑1ri ation 0 g, 20 ft, en one 700lbs
Non-Water Supply Well: chips
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation Sin IGRAPsLI! CI[ a NIM
OM TO MATERIAL IINPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 0 :ft. ft.
❑Aquifer Test ❑StormwaterDrainage
❑Experimental Technology I]Subsidence Control
❑Geothemral(Closed Loop) ❑Tracer I TO DESCRIPTION(cabr,bardnev soRtmek etc.
0 Geothermal(Heating/Cooling Return) ❑0ther(explain under#21Rernalks) 0 ft. 10 ft• Red clay
7/15/2022 11 .ft. so fc, Saperlite
4.Date Well(s)Completed: 31 ft. 80 ft. Rocky clay
5.Well Location: S1 ft. 100 ft. Granite
Mark deaton 101 'ft, 140 ft, Soft brown rock
Facility/Orvner Name Facility 1D#(if applicable)
141 ft- 200 ft- Soft brown rock
329 chestnut ridge rd kings mountain nc
Physical Address,City;and Zipr2I'1iE11ZAltKtfi
Gaston
County Parcel IdentiticationNo.(PIN) a Lt - Lis'
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees; 22.Certification: Ott-
ZQ22
(if well field,one lat/long is sufficient) J�p,/ ,t ,�
�^M Iniviif"^ '^
16/2022
35016'21.198" N 81020'12.0984" by i�i.. '�' ill;
Signature of Certified Well Contractor � ' Date
6.1s(are)the wele ermanent or ❑Temporary By stguhrg this form,I hereby ceraiy that Inc well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards mid that a
7.Is this a repair to an existing well: ❑Yes o•No copy of this record has been provided to the well mvner.
if rhls Is a repair,fill out known well construction Information and explain the nature of the
repair under#21 remarks section or ram the back of this fora. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S:Number of wells constructed: 1 construction details. You may also attach additional pages ifnecessary.
For multiple.injection or non-water supply wells ONLY with the same construction,you cart
24.Submittal Instructions:
submit one form
9.Total well depth below land surface: 200 (rut) 24a. .For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if•dl'fferent(example-3@200'and 2 @ 100) Construction to the following:
I
10.Static water level below top of casing: 20 (rut,) Division of Water Qaallty,lInformation Processing Unit,
ljwater level is above cashsg,use"+" 1617 Marl Service Center,Raleigh,NC 27699.1617
6 24b.For Injection Wells: In addition
11.Borehole diameter: (in.) to sending the fool to the address in 24a
• above, also submit a copy of this form within 30 days of completion of well
12.We construction method: construction to the following:
(i.e.auger,mCrty,cable direct push,etc.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Cent i,Raleigh,NC 27699-1636
13..FOR WATER SUPPLY WELLS ONLY:
30 Method of test: Air lift 24c.For Water Snugly&Geothermal WellI: In addition to sending the form to
13a.Yield(gpm) the address(es)above, also submit orie copy of this form within 30 days of
Hth Amount: 12ounces completion of well construction to the county health department of the county
13b.Disinfection type: where constructed. I
Form CN-I North CamGwr Departmentof Snvimnmont and NatnralResources-Division of WaterQuality
Revised Jan.2013
i ,